Simulated Clinical Patient Scenario
Patient Information
Name: R. J.
Age: 72
Sex: Male
Height: 5’10”
Weight: 108 kg (238 lb)
Code Status: Full Code
Allergies: Penicillin (rash), shellfish (hives)
Admitting Diagnosis: Congestive Heart Failure Exacerbation
Date of Admission: 2 days ago
Past Medical History
Chronic systolic heart failure (EF 30%)
Coronary artery disease
Myocardial infarction 6 years ago
Hypertension
Type 2 diabetes mellitus
Chronic kidney disease stage III
Atrial fibrillation
Hyperlipidemia
Obstructive sleep apnea
Chronic obstructive pulmonary disease (COPD)
Peripheral vascular disease
Former smoker (40 pack-year history)
Surgical History
CABG x3
Left carotid endarterectomy
Cardiac catheterization
Right knee replacement
Social History
Lives at home with wife
Ambulates with cane
Former smoker
Drinks 1–2 beers weekly
Uses CPAP at night but reports “sometimes forgetting”
, Current Hospital Course
Patient presented to the emergency department with worsening shortness of breath,
orthopnea, productive cough, lower extremity swelling, fatigue, and weight gain over the
past week. Reports sleeping in a recliner for the last 3 nights due to dyspnea when lying flat.
Patient admitted to telemetry unit for CHF exacerbation and fluid overload.
Head-to-Toe Assessment
Neurological
Alert and oriented x4
Speech clear
Follows commands appropriately
Reports fatigue and generalized weakness
Pupils equal and reactive bilaterally
HEENT
Mucous membranes slightly dry
No facial droop
Jugular venous distention present at 45 degrees
Respiratory
Dyspnea with minimal exertion
Orthopnea present
Bilateral crackles in lower lung bases
Diminished breath sounds posteriorly
Productive cough with frothy pink-tinged sputum
Using accessory muscles intermittently
Cardiovascular
Atrial fibrillation noted on telemetry
S1/S2 present
Irregular rhythm
3+ pitting edema bilateral lower extremities
Peripheral pulses weak but palpable
Capillary refill 3 seconds
Skin cool to touch
Gastrointestinal
Abdomen soft, rounded
Bowel sounds active x4
Reports decreased appetite
Denies nausea/vomiting
Last bowel movement yesterday
Genitourinary
Foley catheter in place
Patient Information
Name: R. J.
Age: 72
Sex: Male
Height: 5’10”
Weight: 108 kg (238 lb)
Code Status: Full Code
Allergies: Penicillin (rash), shellfish (hives)
Admitting Diagnosis: Congestive Heart Failure Exacerbation
Date of Admission: 2 days ago
Past Medical History
Chronic systolic heart failure (EF 30%)
Coronary artery disease
Myocardial infarction 6 years ago
Hypertension
Type 2 diabetes mellitus
Chronic kidney disease stage III
Atrial fibrillation
Hyperlipidemia
Obstructive sleep apnea
Chronic obstructive pulmonary disease (COPD)
Peripheral vascular disease
Former smoker (40 pack-year history)
Surgical History
CABG x3
Left carotid endarterectomy
Cardiac catheterization
Right knee replacement
Social History
Lives at home with wife
Ambulates with cane
Former smoker
Drinks 1–2 beers weekly
Uses CPAP at night but reports “sometimes forgetting”
, Current Hospital Course
Patient presented to the emergency department with worsening shortness of breath,
orthopnea, productive cough, lower extremity swelling, fatigue, and weight gain over the
past week. Reports sleeping in a recliner for the last 3 nights due to dyspnea when lying flat.
Patient admitted to telemetry unit for CHF exacerbation and fluid overload.
Head-to-Toe Assessment
Neurological
Alert and oriented x4
Speech clear
Follows commands appropriately
Reports fatigue and generalized weakness
Pupils equal and reactive bilaterally
HEENT
Mucous membranes slightly dry
No facial droop
Jugular venous distention present at 45 degrees
Respiratory
Dyspnea with minimal exertion
Orthopnea present
Bilateral crackles in lower lung bases
Diminished breath sounds posteriorly
Productive cough with frothy pink-tinged sputum
Using accessory muscles intermittently
Cardiovascular
Atrial fibrillation noted on telemetry
S1/S2 present
Irregular rhythm
3+ pitting edema bilateral lower extremities
Peripheral pulses weak but palpable
Capillary refill 3 seconds
Skin cool to touch
Gastrointestinal
Abdomen soft, rounded
Bowel sounds active x4
Reports decreased appetite
Denies nausea/vomiting
Last bowel movement yesterday
Genitourinary
Foley catheter in place
